Future of Hypertension: The Need for Transformation

Abstract

Hypertension is one of the most pressing public health challenges. It is recognized as the biggest contributor to the global burden of disease. Globally, in 2015, 1.13 billion adults had raised blood pressure (defined as systolic blood pressure [SBP] of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher). In 2015, over 19% of all deaths were linked to elevated SBP (>115 mm Hg). The global burden of hypertension has been growing over time, largely driven by population growth, changes in lifestyle, and aging. The number of adults with raised blood pressure (defined as SBP of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher) increased from 594 million in 1975 to 1.13 billion in 2015, with the increase largely in lowand middle-income countries. Approximately 75% of people with hypertension (1.04 billion) live in lowand middle-income countries. Likewise, deaths from elevated SBP grew by an average of 1.6% per year between 1990 and 2015. When stratified by developmental status as measured by the sociodemographic index, countries with lower developmental status showed greater increases in the number of deaths linked to elevated SBP than the most developed countries. The largest percent increase deaths related to elevated SBP between 1990 and 2015 occurred in low-middle countries (107%). Alarmingly, hypertension is controlled in less than a fifth of patients worldwide. Furthermore, there are vast global disparities in hypertension awareness, treatment, and control, with challenges that are particularly acute in lowand middleincome than in high-income countries. According to 2010 data, compared with lowand middle-income countries, highincome countries had proportionately double the awareness (67.0% versus 37.9%) and treatment (55.6% versus 29.0%) and 4× the control among patients with hypertension (28.4% versus 7.7%). Detecting hypertension early and taking measures to control it may be a cost-effective way to reduce the hypertension-related disease burden. However, many challenges exist, beginning with early detection and ongoing follow-up. Hypertension is often referred to as the silent killer because there are often no symptoms or warning signs. As a result, it is critical to check blood pressure regularly. Yet, there is no easy way to measure blood pressure. The diagnosis of hypertension is still based primarily on measurement using a cuff. Once hypertension is diagnosed, treatment can be life long, regimens are relatively arbitrary and not precise, and often comes with side effects. Effective, inexpensive blood pressure–lowering drugs are offered to, and regularly used by, only a fraction of the patients who need them. In addition, as discussed below, the guidelines for treatment—based on data from RCTs (randomized controlled trials—have many problems. Finally, diagnosis based on blood pressure measurements alone neglects the many factors that influence blood pressure: social, behavioral, dietary, physical activities, other variables. Finally, the pathophysiology and genetics of primary or essential hypertension (defined as hypertension that does not have a secondary cause) remain unclear.